Problem Wounds and Drains Week 2024 PDF

PROBLEM WOUNDS A N D DRAINS ALISON LIVESEY 2024  L E A R N I N G OBJECTIVES Be able to: understand strategies for dealing with infected wounds understand and describe the consequences of improper treatment of infected wounds describe the management of foreign bodies a...

PROBLEM WOUNDS A N D DRAINS ALISON LIVESEY 2024  L E A R N I N G OBJECTIVES Be able to: understand strategies for dealing with infected wounds understand and describe the consequences of improper treatment of infected wounds describe the management of foreign bodies and internally penetrating wounds describe the distinction between active and passive drains identify means of producing active or passive drainage describe scenarios that may benefit from surgical drainage describe drainage of the chest and abdomen Problem Wound and Drains October 2025 2  F A C T O R S T H A T C A N A F F E C T W O U N D HEALING Patient factors Poor nutrition/malnourishment (low protein levels) Concurrent disease (hyperadrenocorticism, hypoT4, cancer) Immunosuppressive drugs/chemotherapy Cat vs dog Wound interference Wound factors Blood supply Infection/Contamination Perfusion Tissue viability/fluid accumulation Movement/pressure/skin tension Neoplasia Problem Wound and Drains October 2025 3 P R O B L E M WOUNDS Disrupted wounds Pressure wounds Wounds in areas of Movement and Pressure Problem Wound and Drains October 2025 4  F A C T O R S T H A T L E A D T O D I S R U P T E D WOUNDS Wound tension Infection Haematoma or Seroma Suturing nonviable tissue Wound molestation Problem Wound and Drains October 2025 5 DEHISCENCE Problem Wound and Drains October 2025 6 H A L S T E D ’ S PRINCIPLES 1. Gentle tissue handling 2. Meticulous haemostasis 3. Preservation of blood supply 4. Strict aseptic technique 5. Tension free closure 6. Accurate apposition of tissues 7. Eliminate dead space William Stuart Halstead 1852 - 1922 Problem Wound and Drains October 2025 7  P R E S S U R E WOUNDS Decubital ulcers Bony prominences Greater trochanter Tuber coxae Acromion of scapulae Ischial tuberosity Lateral humeral epicondyle Lateral tibial condyle Lateral malleolus Sides of digit 5 Olecranon Calcaneal tuberosity Sternum Repeated trauma when sitting or lying (tissue compression) Prolonged recumbency (neurological/spinal patients/multi orthopaedic patients Bandage induced pressure sores Problem Wound and Drains October 2025 8  P R E V E N T I O N O F D E C U B I TA L U L C E R S Turn recumbent dogs every 1-4 hours Meticulous nursing/skin care-clean and dry-well-padded bed Treat underlying condition to prevent recumbency Relieve pressure Donut dressing Splints Problem Wound and Drains October 2025 9  P R E V E N T I O N O F B A N D A G E SORES Proper bandage placement and monitoring Prevent slipping Not overtight Careful padding over bony prominences Less is more Care with rigid fixation Casting, splints Place on the side of limb opposite the healing wound Be aware of swelling Today’s VeterinaryPractice Casting too early Use bivalve casts and check regularly Problem Wound and Drains October 2025 10 M O V E M E N T A N D PRESSURE Wounds over joints Tension, compression and shearing forces Meticulous attention to closure Casting/splinting Paw pad wounds Compression with weight bearing Spread with weight bearing pulls wound edges apart Suture pull through Bandaging/splinting Palmar/plantar – prevent weight bearing on pad for 2 weeks Tension relieving sutures far-near-near-far, large diameter monofilament suture Will eventually heal by granulation if owner will tolerate Sock/bandage to keep clean, lead walks Problem Wound and Drains October 2025 11  C H R O N I C W O U N D S – M O V E M E N T A N D PRESSURE Axillary and inguinal wounds Collar wounds Shearing movement with ambulation Meticulous closure Debride and close Resect and close Reconstructive flaps Problem Wound and Drains October 2025 12 I N F E C T E D WOUNDS Inhibits wound healing Chronic/recurrent wounds Causes dehiscence of closed wounds Surface contaminants do not often reflect infective agent Deep tissue culture Nature of wounding Puncture from a bite Underlying causes Foreign bodies Grass seeds, sx implants, bone sequestra, debris/contaminants Problem Wound and Drains October 2025 13  N A T U R E O F WOUNDING More energy applied to tissues More vascular damage Less blood supply, less O2, fewer plasma proteins Slower inflammatory response, prolonged inflammation Contaminated bacteria more likely to cause infection in damaged tissues Shearing creates dead space Penetrating FBs create dead space FBs create avascular surface for bacteria Problem Wound and Drains October 2025 14 T R A U M A , C O N T A M I N A T I O N A N D INFECTION SKIN SUBCUTANEOUS TISSUE MUSCLE Problem Wound and Drains October 2025 15  T R A U M A , C O N T A M I N A T I O N A N D INFECTION SKIN SUBCUTANEOUS TISSUE DEAD SPACE MUSCLE Warm Moist Low O 2 Proteins Immune response cannot penetrate Problem Wound and Drains October 2025 16  T R A U M A , C O N T A M I N A T I O N A N D INFECTION Immune response can only reach edges Walled off area Abscess SKIN SUBCUTANEOUS TISSUE MUSCLE Problem Wound and Drains October 2025 17 T R A U M A , C O N T A M I N A T I O N A N D INFECTION SKIN SUBCUTANEOUS TISSUE MUSCLE Problem Wound and Drains October 2025 18 T R A U M A , C O N T A M I N A T I O N A N D INFECTION Heals by granulation Chronic draining sinus Abscess bursts Poor drainage Devitalised tissue Drains FB SKIN SUBCUTANEOUS TISSUE MUSCLE Problem Wound and Drains October 2025 19  F O R E I G N B O D I E S A N D P E N E T R A T I N G WOUNDS Wood splinters, grass awns, straw, broken teeth or nail of an attacker Common entry Points Interdigital Ear canal Conjunctiva Oropharynx Draining Tract/Sinus FBs Surgical implants, sutures, cotton swab strands bone sequestra Problem Wound and Drains October 2025 20  A P P R O A C H T O A D R A I N I N G TRACT Diagnostics Radiographs – plain or with contrast Impression smear Bacteriology – C+S CT/MRI Surgically explore tract fully (open along tract +/- probing) Identify and remove cause Leave to heal by 2nd intention or excise tract en bloc Tissue sample for culture (anaerobic and aerobic) Image-PDSA Thoroughly lavage Empirical antibiotics Change based on culture results Problem Wound and Drains October 2025 21  P E N E T R A T I N G W O U N D S – C A T B I T E ABSCESS Cat bite abscess Puncture wounds with some crush injury Clinical infection majority of cases Presentation Rapidly occurring swelling Brave cat/timid cat Ruptured/burst and presented for wound Systemically unwell (pyrexic, lethargi,c painful) with no visible swelling Should be top differential in cats with PUO Lameness/not using limb/tail May occur in areas where difficult to get drainage naturally Problem Wound and Drains October 2025 22  C A T B I T E A B S C E S S - TREATMENTS Presented before abscessation No necessary to explore as FB low (hair? Tooth? Nail?) Antibiotics Pain relief (NSAIDs if hydrated) Presented with abscessation Antibiotics do not penetrate pus Lance, drain, flush, place drain? (dead space) Antibiotics Pain relief (NSAIDs if hydrated) Pasturella, Staph, Strep (aerobes + anaerobes) Broad spectrum (amoxy-clav, clindamycin, cephalosporins Problem Wound and Drains October 2025 23  O R O P H A R Y N G E A L P E N E T R AT I N G T R A U M A - S T I C K INJURIES Med to large breed dogs; collies, Labradors, spaniels Acute within 7 days of presentation oral pain, dysphagia and dyspnoea, submandibular and cervical swelling, abscesses, pain on opening of the mouth, pyrexia Injury observed or knowledge of stick catching/carrying Chronic > 7 days before presentation more common systemically well recurrent cervical or submandibular swelling or discharging sinus Problem Wound and Drains October 2025 24  O R O P H A R Y N G E A L P E N E T R AT I N G T R A U M A - S T I C K INJURIES Rostral pharyngeal wounds enters at acute angle penetrates pharynx at the tonsil or just behind last molar can lead to temporal, masseter or retrobulbar involvement Lateral pharyngeal wounds most common stick enters obliquely damages parapharyngeal & cervical tissues, intermandibular area or cranial thorax Dorsal pharyngeal injuries stick enters from directly in front of the dog damages soft palate and dorsal pharynx can lacerate the oesophagus Problem Wound and Drains October 2025 25  O R O P H A R Y N G E A L S T I C K I N J U R I E S - TREATMENT Acute Examination of oral cavity and pharynx Identify site of injury and retrieve foreign material Cervical and thoracic radiographs Soft tissue swelling, loss of detail, gas between tissue planes/ subcutaneously Pneumomediastinum if oesophageal perforation To prevent chronic fistulous tracts surgically explore via ventral midline approach, inspect dorsal oesophagus for tears Chronic recurrent cervical swellings and discharging sinuses original injury often unknown difficult to treat meticulous exploration of tracts and debridement of all diseased tissue remove all the diseased tissue and hopefully the foreign material with it Problem Wound and Drains October 2025 26 Problem Wound and Drains October 2025 27  S U R G I C A L DRAINS Tissue apposition and obliteration of dead space Remove fluid that provides media for bacterial growth Relieve pressure that can affect tissue perfusion Remove inflammatory mediators, bacteria, necrotic tissue, foreign material Drains themselves incite an inflammatory response Open drain (passive) Closed suction drain (active Problem Wound and Drains October 2025 28 Problem Wound and Drains October 2025 29  O P E N P A S S I V E DRAINS Penrose Capillary action Gravity Drainage along outside of tube High surface area to volume ratio Fenestration contraindicated Problem Wound and Drains October 2025 30  PENROSE DRAINS Advantages Inexpensive Soft/malleable Low tissue trauma Disadvantages Cannot quantify fluid production Not useful when large volume drainage required Require gravity Cannot use in the thoracic cavity Cannot use to flush wound More risk of ascending infection Problem Wound and Drains October 2025 31  P L A C I N G A P E N R O S E DRAIN Proximal end placed deep in wound/dead space Exit via stab incision adjacent to wound- dependent Distal end secured to skin with single SI suture through drain Cover with dressing Must not exit through incision Do not use for flushing Can secure proximal end with a single suture (internal or external suture) Care with neoplasia - place close to wound incision Need to clean regularly and attempt to quantify drainage production Problem Wound and Drains October 2025 32 PLACING A PENROSE DRAIN Problem Wound and Drains October 2025 33 C L O S E D S U C T I O N D R A I N S (ACTIVE) Tubing and suction device/vacuum Goes into wound Fenestrations Airtight cavity Less risk of contamination Problem Wound and Drains October 2025 34  C L O S E D S U C T I O N D R A I N S (ACTIVE) Advantages More effective fluid removal Reduced risk of ascending infection Easily portable Doesn’t require a lot of dressing Can collect and record fluid Constant suction decreases occlusion Disadvantages Loss of vacuum if wound is not airtight Occlusion by clots Premature removal by patients often requires buster collar Problem Wound and Drains October 2025 35  Closed Suctions Drains trocar Problem Wound and Drains October 2025 36 Friday, 30 September 39  P L A C I N G A C L O S E D S U C T I O N DRAIN From inside to outside Choose drain exit site easy to cover, easy to manage, comfortable for the patient Tunnel to site with forceps Incise skin over forceps hole no larger than the tubing some have a trocar Grasp tubing from inside wound and pull it outwards with forceps Fenestrated portion of tubing should be dependent Entire fenestrated portion must be in wound to allow suction/airtight Purse string suture and finger trap Attach grenade Problem Wound and Drains October 2025 37 TODAY’S VETERINARY PRACTICE, November/December 2016  A C T I V A T I N G SUCTION Best to wait 4-6 hours post op Compress the grenade with evacuation port open Close the port/cap the port/clamp tubing Release compression – creates negative pressure Cover exit site with adhesive dressing Use shirt or stockinette or bandage to protect tubing/grenade Use BC if can interfere Problem Wound and Drains October 2025 38  M A I N T A I N I N G A N A C T I V E S U C T I O N DRAIN Monitor and record fluid amount quality Empty drain at least once daily or when it is half full strength of suction decreases as grenade fills Grenades lose suction as they reach 20-30% capacity Remove when fluid production is